Over the last several years, the fire service has placed increasing emphasis on rapid intervention teams (RITs) to help ensure firefighter safety. An essential skill for any RIT is to make sure the paths of egress from the fire building are open (and stay open) for crews that need to make an emergent exit. Called “soften the exit” (or “harden the exit” by some), this task also ensures that the RIT can safely enter the structure if necessary.
This same concept can be applied to the extrication scene. When the path of egress (aka, path of removal) is properly prepared–all glass removed, debris relocated to the warm or cold zones, exit strategies evaluated and exits secured–the potential for injury to patients and firefighters is reduced. As such, I believe we need to introduce the concept of “harden the egress” to the extrication community. Harden the egress means rescuers should take the necessary steps to ensure a safe and effective path of egress for the patients and first responders involved in patient removal. As a general rule of thumb, this area should extend from the patient to at least the warm zone and at best the waiting transport vehicle.
Train Them Right
The first and last lines of defense for hardening the egress: the disentanglement group supervisor–typically a company officer. They have the ability to set the standard for a well-established path of egress.
Preplanning and training are the best ways for supervisors to underscore to their crews the importance of hardening the egress. After all, it’s unreasonable to think that crews will apply the concepts and simple solutions found in this article for the first time during an actual incident, when emotions are high and operations are critical. Rather, they need to train on how to properly harden the egress over and over again, so it becomes second nature.
During the process of disentanglement and other tactics, the disentanglement group supervisor should communicate closely with the medical personnel on scene. If the supervisor receives patient condition reports and medic input, they can conduct a more accurate cost-benefit analysis to determine the appropriate amount of time and energy their team should put into hardening the egress. For example, if the patient is unstable because of life-threatening injuries or if there is a need for immediate resuscitation, then the level of protective interventions applied to the path of egress will be reduced.
One challenge for the supervisor on the extrication scene: ensuring the disentanglement group maintains an appropriate level of intensity once the path of egress has been established. The group may believe that their job has been completed and therefore become too relaxed about scene safety. But rescuers should take as much pride in finishing the overall job as they do in completing their disentanglement tactics. With this in mind, the supervisor may have to motivate the group to maintain situational awareness and continue helping in the process of hardening the egress.
Protect Against Sharps
A sharps hazard refers to any component of the vehicle (e.g., glass, plastic, metal) that could cause abrasions, lacerations or puncture wounds to patients or rescuers. Considering the dynamics of a motor vehicle collision and the resulting damage, there are almost always sharps hazards. And many of these hazards are created by the tactics rescuers employ to create the path of egress. Knowing this, rescuers should take a few extra seconds to mitigate those hazards.
There are various types of homemade and commercial devices to cover sharp edges. I’m a technical consultant for Protecto Wrap Company, which makes Extrication Wrap, a safety tape that adheres to steel, aluminum, glass, vinyl, plastic and wood, as well as almost any painted or unpainted surface. Extrication Wrap is basically a thin facer that allows the user to quickly cover sharp, irregular areas.
Another commercially available device is the Kovenex Rapid Response Blanket, a high-performance flame- and tear-resistant blanket that provides protection against shattered glass particles and sharp metal edges. Although it’s typically considered to be a patient-protection blanket, rescuers can use the blanket (or pieces of the blanket) to cover sharp edges.
Lukas and Holmatro also make protective sheets with sewn-in magnets that are used to cover sharp edges. They’re made with a tear-resistant outer lining with internal layers of non-woven fabric.
Many departments rely on homemade covers, such as old hose sections, moving blankets, floor mats, mechanic fender covers, etc. While these items may not be rated for the specific application, they do provide some level of protection from sharp edges.
Regardless of what type of edge-protection equipment or products you use, try to store them in bags or containers that are staged with other equipment or positioned in a safe area just outside the hot zone–any convenient location where rescuers will see them–and remember to use them when clearing the removal pathway.
Stage Tools
We usually hear references to staging tools early in the incident. When tools are properly staged outside the hot zone and ready for immediate deployment, it’s more likely that rescuers will choose the appropriate tool for the required task. Common tools that need to be staged include hydraulics, reciprocating saws and extra cribbing. For the purpose of hardening the egress, we should also stage anything that can be used for sharps protection, as well as oil dry and EMS supplies, including the stretcher and spinal immobilization devices.
It’s important to note that the task of staging tools also refers to placing tools back in a staging area once they have been used. Tools not being used present trip hazards in and around the hot zone. It’s important to move these tools out of the way, especially once the path of egress has been completed and patient removal is imminent. (More on slip and trip hazards in the next section.)
In addition to staging hydraulic tools following the completion of disentanglement tactics, consider cutting off the power unit or throttling down the engine. In a recent test with a digital level sound meter, a simo power unit put off a reading of more than 90 decibels at a distance of 10 feet. The reading was approximately 75 decibels at 30 feet. It’s important to limit the amount of noise on the scene when possible to facilitate communication in critical situations.
Limit Slip & Trip Hazards
The hot zone is usually very congested and dynamic, creating the potential for slip and trip hazards, so we need to do what we can to eliminate these hazards.
When it comes to trip hazards specifically, many fall injuries occur on level ground when people trip over unexpected objects in their path. Some factors that could lead to trips may be present in the hot and warm zones prior to the arrival of emergency personnel: debris from the collision, poor lighting and uneven terrain. Unfortunately, most of the trip hazards in the hot and warm zones are created by the responders themselves: hydraulic hoses, air hoses, electrical cords, random equipment not properly staged, vehicle parts and debris removed during tactics.
As for slip hazards, most of these hazards (e.g., oily and wet surfaces, tempered glass fragments, laminated glass) are present prior to responders’ arrival.
Regardless of how or when these hazards were created, the disentanglement group supervisor and the safety officer should be on the lookout for any slip and trip hazards in the hot and warm zones. And they should try to mitigate these issues as quickly as possible so rescuers don’t have to worry about footing and movement within the work area.
With this in mind, follow these simple mitigation measures for slip and trip hazards:
- Spread oil dry or dirt on spills and leaks;
- Remove debris from the hot zone to a designated area;
- Stage tools in a designated area just outside the hot zone; and
- Mark hazards with cones or signaling devices.
If it’s not possible to mitigate these hazards in an acceptable amount of time, the supervisor should communicate the hazard types and locations to all personnel in the area. For these situations, follow these work practices:
- Take your time and pay attention to where you are walking;
- Step over or around obstructions–not on them;
- Adjust your stride to a pace that’s suitable for the tasks;
- Make wide turns and change directions slowly; and
- Walk with your feet pointed slightly outward.
Make an Appropriate Path of Egress
The best way to free a trapped victim is to provide the most inline movement to a long spinal board. Make sure the final opening created is as large as possible and in line with the direction of the patient’s spine. Simple things like positioning tools with the handle away from the patient movement or removing an additional post will allow rescuers to gain valuable inches. Inches may appear as minimal gains, but in many cases, they’re the difference between manipulating the patient and smoothly removing them from the vehicle.
Over the years, there have been heated discussions as to whether we need to completely remove parts of the vehicle, including doors and roofs, in certain extrications. There is no “always” or “never” answer; the situation will depend on many factors, such as access, tool availability and patient condition. Regardless, the disentanglement group supervisor should consider completely removing or displacing any vehicle parts that will provide a cleaner and safer path of egress.
Prepare for Patient Movement
An old, street-smart paramedic once said, “Don’t bring the stretcher and backboard to the vehicle until you have all the necessary parts and they are assembled correctly.” “Correctly assembled” means having the stretcher straps unbuckled and out of the way, the backboard on the stretcher, three properly positioned straps, and head blocks ready to place into in position. Equipment should be assembled and staged just outside the hot zone so that when the patient has been freed from the entrapment, no time is lost in the transition to the long spinal board and the awaiting ambulance. Other advantages: It cuts down on the amount of time that less-equipped personnel need to operate in the hot zone, and it decreases the amount of patient manipulation to apply straps to the long spinal board.
Once the path of egress has been appropriately established and the spinal immobilization equipment has been placed in position, the disentanglement group supervisor can give the medic the go-ahead to begin directing personnel for patient removal. This transition should be confirmed with the medic and communicated to all personnel on scene.
If we’re doing our jobs correctly, we will have properly hardened the egress, allowing the medic and their crew to focus on patient movement, not having to worry about sharps, trip and slip hazards, or ill-placed tools.
A Final Word
Regardless of what tactics are needed to successfully mitigate the incident, the concept of hardening the egress is the same. Rely on the group supervisor to evaluate the situation and implement the necessary steps. Take the appropriate measures to make the most appropriate path of egress. During that time, have EMS or other personnel prepare the appropriate equipment for patient removal. Once disentanglement tactics are complete, ensure the area is clear of any slip and trip hazards, including tools, or sharps hazards. It may not be the most glorious work, but it has to be done and, in some cases, is a good measure of the competence and ability of the responding units. It will not only make for safer operations but will also leave a lasting impression of professionalism with other responding agencies.
